Coronary Heart Disease (Sakit sa Puso) in

the Philippines: A Guide to Patient

Education, Prevention, and Treatment

Karissa Chesky, Krishan Ferrer, Isaiah Cabebe, Arthur Gallo MD, Dante
Morales MD, Annabelle Santos Volgman MD, Malathi Srinivasan MD,
Julieta Gabiola MD

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 Table of Contents

Case Presentation ………………………………………………………………………………. 3

Introduction …………………………………………………………………………………….. 4

Coronary Heart Disease (CHD) ……………………………………………………………….. 8

Causes of CHD ……………………………………………………………………………….… 11

Manifestations of CHD ………………………………………………………………………… 12

Risk Factors of CHD …………………………………………………………………………… 15

Prevention of CHD …………………………………………………………………………….. 29

Diagnosis of CHD ……………………………………………………………………………… 32

Treatment of CHD ……………………………………………………………………………... 38

Coronary Heart Disease (CHD) Initiatives in the Philippines ……………………….…….. 45

ABC's for Global Health ………………………………………………………….……………. 47

Conclusion …………………………………………………………………………………….. 51

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Case Presentation

A 52 year old Filipino man presented to the emergency room with severe substernal chest pain,

shortness of breath, and dizziness. The chest pain was described as heaviness and squeezing in

character. On physical examination, the patient had a blood pressure (BP) of 80/50 mmHg and a

heart rate of 120 bpm with cold, clammy skin. An electrocardiogram (ECG) revealed changes

suggestive of a massive heart attack. Serum troponin1, a cardiac enzyme detected by a blood

draw, was 10 times the upper limit of normal, suggesting significant heart muscle injury. On the

way to the cardiac catheterization laboratory2, the patient's BP and pulse were barely appreciable,

hence advanced cardiac resuscitation was administered. He was pronounced dead an hour later.

This mode of presentation of a heart attack is common in the Philippines, where people with

unrecognized and undiagnosed preventable cardiovascular diseases often present late in their

disease. Nationally, basic medical care is lacking, with a paucity of resources available for

prevention, education, and consistent treatment. Families commonly sell their possessions,

including their homes, to pay for medical needs such as emergency room visits, hospitalization,

and procedures. Medications are not adhered to as basic needs, whereas others like food, take

priority. Economic losses are compounded from loss of productivity by the patient and family

members who will need to take care of the patient after a stroke, heart attack or heart failure.

Paper objectives for target audience: medical practitioners, students, and patients

1. To enhance awareness of coronary heart disease (CHD) causes, manifestations, risk

factors, prevention, diagnosis, and treatment to help individuals modify their lifestyle to

prevent or reduce the progression of CHD.

1
Troponin: a protein of muscle that together with tropomyosin forms a regulatory protein complex controlling the
interaction of actin and myosin and that when combined with calcium ions permits muscular contraction; significant
increase denotes death of heart muscle
2
Catheterization laboratory (cath lab): a specialized area in the hospital where doctors perform minimally invasive
tests and advanced cardiac procedures to diagnose and treat cardiovascular disease
 2. To promote earlier diagnosis of CHD so intervention can occur.

3. To help shape public policies and direct resources to areas with the most significant need.

Introduction

Cardiovascular diseases (CVD) are the leading causes of mortality globally, causing

approximately 18 million deaths each year (World Health Organization, 2021), representing

about 32% of all global deaths. Of these deaths, 85% were due to heart attack and strokes. Over

75% of CVD deaths occur in low and middle income countries. Men are more commonly

affected than women, and incidence usually starts around the fourth decade of life, increasing

with age. In the United States, a person dies from CVDs every 36 seconds, accounting for 1 of

every 4 deaths. Coronary heart disease (CHD), a common subset of CVDs, is the most common

heart disease in the United States across all gender and racial groups (CDC, 2020).

In the Philippines, the top three causes of death in 2021 included CHD, other cerebrovascular

diseases or stroke, and cancers. Over half a million CHD cases were reported in 2021,

contributing to approximately 19% of the total deaths in the country. This number increased from

less than half a million CHD cases in the first six months of 2020, contributing to approximately

17% of total deaths in the country (Philippine Statistics Authority, 2021). It is unclear if the

increased number of total deaths could be attributed to decline in care and treatment due to

COVID. Overall from 2015 to 2021, CHD ranked as the number one cause of death and

disability in the Philippines.

CHD is also one of the most common non-communicable diseases (NCD) affecting patients

worldwide. NCDs, which also include hypertension, diabetes, dyslipidemia, chronic obstructive

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pulmonary disease (COPD), heart diseases (CHD), stroke, chronic kidney disease, and cancer,

cause approximately 71% of deaths annually (WHO, 2021). NCDs cause approximately 3 out of

4 deaths, and these diseases affect mostly low and middle-income countries.

Table 1

Number and Rank of Registered Deaths, Percent Shares, and Ranks by 50 Leading Causes of
Death, Philippines: January to June, 2020-2021 (Abridged).

Cause of Death Prevalence Rank Percent Change of

number in 2021 Cases from January
2020 - January 2021

Total 595,626

Ischemic Heart Diseases (Coronary Heart 56,757 1 17.4

Disease)

Cerebrovascular Diseases or Stroke 30,796 2 0.7

Cancers 17,343 3 -16.3

Diabetes Mellitus 19,802 4 10.2

COVID-19 virus identified 17,156 5 1,300.5

Hypertensive diseases 16,146 6 8.3

Pneumonia 13,738 7 -32.3

Other heart diseases 10,615 8 9.3

COVID-19 virus not identified 9,594 9 28.4

Chronic lower respiratory infections 9,248 10 -15.6

Remainder of diseases of the 8,527 11 -0.1

genitourinary system

Despite improvements in intervention for CHD and acute coronary syndrome, CHD still remains
as the top cause of mortality. Probable causes for this increase include prevalent risk factors
such as diabetes, hypertensive diseases and other heart diseases (all CV diseases).

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Major contributing and modifiable risk factors for CHD include dyslipidemia, smoking,

hypertension, abdominal obesity, diabetes, lifestyle factors like dietary lack of fruits and

vegetables, and a sedentary lifestyle. These are also noted as the main drivers for most deaths

and disabilities. Recent studies comparing the relationship between atherosclerotic-related risk

factors and diseases in the Philippines have shown an increasing prevalence of hypertension,

diabetes, dyslipidemia, smoking, and central obesity.

Table 2

Trends of the Top 10 Leading Causes of Deaths in the Philippines from 2010 to 2022 (Philippine
Statistics Agency).

No. 2010 2022

1 Diseases of the Heart Ischemic Heart Diseases

2 Cerebrovascular Diseases Cerebrovascular Diseases

3 Malignant Neoplasms Neoplasms

4 Pneumonia Diabetes Mellitus

5 Tuberculosis Hypertensive diseases

6 Chronic Lower Respiratory Diseases COVID-19 Virus Identified

7 Diabetes Mellitus Pneumonia

8 Nephritis, Nephrotic Syndrome and Other heart diseases

Nephrosis

9 Assault Chronic Lower Respiratory Diseases

10 Certain Conditions Originating During the Remainder of diseases of the genitourinary

Perinatal Period system

Ischemic heart diseases, cerebrovascular diseases, and neoplasms have remained the top 3
leading causes of deaths. Notable changes in rankings include that diabetes have since moved
rank from #7 to #4, and hypertensive diseases novelly moved onto the top 10 leading causes of
death list to rank to #5.

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Figure 1

Non-Communicable Disease Country Profiles: The Philippines (World Health Organization)

There is an increasing incidence of NCDs in the Philippines. However, by implementing

treatments and prevention programs, it is predicted that the probability of premature death will
decrease significantly in males and females by 2025.

Coronary Heart Disease (CHD)

CHD is a disease in which the arteries that carry blood to the heart (coronary arteries) become

narrowed from atherosclerosis plaque build-up caused by risk factors (Blumenthal, 2020).

Rupture of a plaque causing complete blockage of a coronary artery results in an acute

myocardial infarction (heart attack) which can be fatal. If the blockage is not complete or has

progressed over time, other conditions can occur, such as angina pectoris, arrhythmias, heart

failure and eventual myocardial infarction.

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Angina pectoris, more commonly known as angina, is chest pain or discomfort due to

insufficient blood being delivered to the heart. It is a mismatch between supply and demand. It is

frequently described as squeezing, pressure, burning sensation or heaviness on the chest

sometimes described as “an elephant sitting on my chest” or “a brick on my chest”. Some may

describe it as the feeling of a tight band around the chest, heartburn or gas. The location of the

pain is usually in the chest area but the sensation may also be felt from the ear lobe, back, neck,

jaw, arms and upper abdomen all the way to the navel. It is usually brought on by exertion,

stress, or anxiety and is relieved by rest or nitroglycerin. It may be caused by coronary

atherosclerosis or spasm of the coronary arteries which can compromise blood flow. The

prevalence of angina varies across populations around the globe. National statistics on angina in

the Philippines have not been recently collected, however smaller studies on angina have been

conducted in Filipino sub-populations. In a 2011 study, approximately 80% of all patients

admitted to the Philippine General Hospital emergency room for acute coronary syndromes had a

chief complaint of angina (Alcover et al., 2011).

In women, angina presentation can differ. In addition to typical symptoms, women can also

experience nausea, vomiting, upper extremity pain, abdominal pain, dizziness, and shortness of

breath (American Heart Association, 2021). These atypical presentations may lead to a delay in

diagnosis and treatment. Women also tend to have more dysfunction of the small arteries

(microvascular dysfunction) rather than blockage of major coronary arteries.

Arrhythmias are irregular or abnormal heartbeats. Common arrhythmias that can occur with

coronary heart disease include premature atrial or ventricular beats, atrial fibrillation (AF), atrial

flutter, and heart blocks. Atrial fibrillation is the most common arrhythmia globally (Mkoko et

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al., 2015). Atrial fibrillation occurs in 2% of Filipinos above 70 years of age according to the

Philippines Department of Health and the Food and Nutrition Research Institute in 2017. It can

sometimes occur in younger individuals (Gervacio, 2017).

Heart failure is the inability of the heart to pump a sufficient amount of blood for the body's

needs. Patients with heart failure usually present with shortness of breath, fatigue, weakness,

cough, or swelling of the legs. A 2017 study of patients admitted from age 19 and older across 17

regions in the Philippines determined the prevalence of heart failure was 16 out of 1000 patients

(Tumanan-Mendonza et al., 2017). This rate is comparatively higher than in other Asian

countries.

Myocardial infarction, more commonly known as heart attack or "Atake sa Puso" in the

Philippines, is caused by a complete blockage of a coronary artery, leading to interruption of

blood flow to the heart, resulting in injury, ischemia, or death of the heart muscle being supplied

by the affected artery. About 45% of heart attacks are “silent,” meaning people may have muted

symptoms, no symptoms of the heart attack at all, or the symptoms were not given attention

(Harvard Health, 2020). These heart attacks are sometimes identified much later when compared

to an old ECG. In the US, someone dies from a heart attack every 36 seconds, and annually

805,000 Americans experience a heart attack, 605,000 of which are first heart attacks and

200,000 are second heart attacks. In 2019, ischemic heart disease was the leading cause of death

in the Philippines with approximately 58,000 and 39,000 deaths in men and women respectively

(Statista 2021).

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Generally, the preceding statistics for angina, arrhythmias, heart failure, and heart attack in the

Philippines are often underreported due to several socio-cultural factors. For example, many

Filipinos often die at home or outside of the hospital due to a lack of access to care. Furthermore,

many of them have not seen a healthcare provider for several years. Many institutions in the

Philippines are just recently implementing electronic medical records, and many are still using

paper charts. Therefore, reporting deaths and/or causes of deaths may not be accurate. Health

care providers tend to ask family members what the person was experiencing prior to death, and

their best assumption will be entered on the death certificate.

Causes of CHD

Most commonly, the main cause of CHD is plaque build-up on the lining of the arteries, a

disease process known as atherosclerosis (Figure 2). This plaque build-up contributes to

instability and narrowing of the artery’s lumen, leading to reduced blood flow to the heart. This

process does not occur instantly, and it may take years for the plaque to build up. Therefore,

early intervention in modifying these risk factors is crucial. Modifiable risk factors including

unhealthy lifestyle habits, namely physical inactivity, improper nutrition, and smoking, can lead

to atherosclerosis. Other risk factors include hypertension, diabetes, and hyperlipidemia. Since

atherosclerosis can develop in different arteries, prevention and treatment can prevent

complications in other organs including the brain (stroke), the kidneys (kidney failure), eyes

(vision loss) and limbs (peripheral artery disease).

The development of atherosclerosis usually begins with excessive cholesterol levels that can

build up in the thin innermost layer of the artery (endothelium). Further endothelial injury, often

due to inflammation, effects of blood pressure elevation, diabetes, or exposure to toxins, such as
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toxins from cigarettes, can cause the further build-up of the plaque. Over time, white blood cells,

low-density lipoprotein (LDL) cholesterol, and calcium travel to the injury site in the

endothelium. The growth of plaques narrows the artery and decreases blood flow, akin to a pipe

being plugged up over time. This reduction of blood flow and subsequent ischemia may manifest

as angina or chest pain initially. When the plaque ruptures, platelets (fragments of cells that help

form blood clots) rush to plug the source of what is interpreted by the body to be bleeding or

injury. This is followed by the formation of a thrombus or clot, a response to plug the "bleeding

site" and the blood vessel leading to a heart attack (myocardial infarction).

Figure 2

Development of atherosclerosis (Shutterstock)

In patients with coronary artery disease risk factors, atherosclerotic plaque can build up in the
lining of the blood vessel. If the risk factors are not controlled, plaque can continue to build-up
and decrease blood flow to the heart muscle cells. The last figure depicts a heart attack in which
the plaque ruptures causing a bleed in the lining of the heart artery. A blood clot forms to stop
the bleeding, which can completely block the blood flow to the heart muscle cells which can die
if the blood flow is not restored within less than 90 minutes.

Manifestations of CHD

CHD manifestations are variable. The presentation can range from asymptomatic (no

symptoms), to vague symptoms such as fatigue, dizziness, feeling unwell, and shortness of

breath, or may present as chest pain, similar to stable or unstable angina or heart attack.

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Stable Angina

Angina is chest or heart pain due to reduced blood supply to the heart. Symptoms occur when the

increased demand for oxygenated blood is not met due to the narrowing of blood vessels caused

by atherosclerosis, endothelial dysfunction, or spasm of the coronary arteries. Stable angina is

predictable chest pain caused by activities that increase demand on the heart like running,

walking, sexual activity, bowel movements, or emotional stress. Chest pains may be described as

pressure, tightness, squeezing, aching, or burning on the chest or breast bone and may radiate to

the neck, jaw, back, shoulders, or arms. Sometimes people will describe it as gas or heartburn,

and it is dependent on the physician to interpret the patient's symptoms. Chest pain generally

lasts for a few minutes and is predictably relieved by rest or medication that can improve the

blood flow of the artery, such as nitroglycerin. Some people curtail or decrease their activities to

prevent these chest pains or take medications such as long-acting nitrates, beta-blockers, or

calcium channel blockers.

In women, symptoms may be more variable or vague, including heaviness in the chest,

abdominal discomfort, fatigue, nausea, lightheadedness, weakness, “not feeling well” or sleep

disturbance. These presentations are sometimes not recognized as heart disease symptoms and

lead to a delay in diagnosis and intervention in women.

Unstable angina

Unstable angina, sometimes referred to as crescendo angina or accelerated angina, is chest or

heart pain resulting from reduced blood supply to the heart that is unpredictable or increasing in

intensity or frequency. Unstable angina is also referred to as rest, vasospastic, or Prinzmetal

angina. Many believe that its classification is sandwiched between stable angina and a heart

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attack and that its occurrence predicts a heart attack. Chest pain occurs at rest, with minimal

exertion, or after angioplasty (a procedure to open up coronary arteries). Pain accelerates rapidly,

lasts longer than a few minutes and may not be relieved by rest or repeated administration of

nitrates. Like stable angina, symptoms occur when there is an increased blood demand to the

heart and there is inadequate supply due to the narrowing of the arteries. The pathophysiology is

thought to be secondary to vasospasm in an already partially occluded coronary artery or arteries.

It is considered a signal that a heart attack or acute coronary syndrome is imminent.

Table 3

Differences between unstable angina from stable angina

Stable angina Unstable angina

Pathophysiology Decrease coronary blood flow Vasospasm in an already compromised

blood flow

Chest pain Chest pain is predictable Unpredictable and accelerates

Trigger With increasing activities, stress May occur at rest

Relief Relieved by rest or nitrates May occur at rest or not relieved by

rest or nitrates

Duration Shorter few minutes Persist and longer duration 5 to 20

minutes

Intensity Variable May be more intense

The symptoms of unstable angina call for urgency and should be immediately seen by a

cardiologist or cared for in an emergency room. In general, if a heart attack is excluded and the

patient is deemed to have unstable angina, they are placed on observation and evaluated for

possible coronary arteriography (injecting dye into the coronary artery to detect obstruction) and

intervention.
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Myocardial infarction (Atake sa Puso)

Myocardial infarction or a heart attack can occur when the coronary blood flow is completely

obstructed. This occurs when plaque on the walls of the coronary arteries ruptures and ultimately

causes blood clots to form. The rupture of these plaque causes blood clots to block off the artery

downstream, causing the cessation of blood flow. When this occurs, the oxygen-depleted heart

muscles become damaged and eventually die, which is called ”infarction”. The decreased

contractility from the damaged area then leads to decreased cardiac output (amount of blood

propelled to the body with each heart contraction) eventually causing heart failure. Many people

who develop a heart attack have a history of angina or chest pains. Others may not have warning

signs and may even have a heart attack without symptoms, coining the term "silent heart attack"

or have a fatal arrhythmia called sudden cardiac arrest.

Some heart attacks are not caused by a complete blockage of the artery and lead to less severe

damage to the heart. These can be caused by spontaneous blood clot resolution, coronary artery

spasms, or microvascular disease (disease of the heart’s smaller arteries).

Risk Factors of CHD

Risk awareness and lifestyle modifications can make a difference in preventing CHD. Many

people are not aware of their risks. It is essential to see a doctor to review family and personal

history to determine risk factors. There are modifiable and unmodifiable risk factors for CHD

(see Table 4). One should consider the multiplier effect, which suggests that the more risk factors

one has, the greater the chance of developing CHD. One can calculate someone’s total risk for

CHD using ASCVD Risk Estimator Plus, a digital risk calculator by the American College of

Cardiology. This program can be accessed here:

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https://www.acc.org/tools-and-practice-support/mobile-resources/features/2013-prevention-guide

lines-ascvd-risk-estimator.

Table 4

Summary of CHD Risk Factors

Unmodifiable Risk Factors Modifiable Risk Factors

Age Cigarette smoking

Sex Hypertension

Family history Abnormal Levels of Blood Lipids/Cholesterol

Personal history of cardiovascular disease Obesity

Metabolic syndrome

Diabetes

Physical Inactivity

Mental conditions: stress, depression, and

Type A personality

Sleep apnea

Toxins/air pollution

Unmodifiable Risk Factors

The following are the risk factors that cannot be modified but are worthwhile to know to

calculate the risk for CHD.

Age: Age and CHD risk are strongly correlated. The risk of CHD will continuously

increase after age 45 in men and after 55 in women. The rate of CHD is expected to

increase as the population ages and as the incidence of obesity, diabetes, hyperlipidemia

15
 and hypertension increase globally. Four out of five people who die of coronary heart

disease are over 65. In 2021, approximately 5% of the total population in the Philippines

were individuals 65 and over (PopulationPyramid, n.d.).

Sex: More men than women develop coronary heart disease. CHD among women tends

to occur a decade later than in men. However, after menopause, the risk approaches that

of men. This phenomenon is believed to be secondary to a decline in estrogen and the

concomitant effect of increased LDL ("bad" cholesterol) and decreased HDL ("good"

cholesterol). Changes in weight and lifestyle further modulate the risk.

Family history: A family history of CHD before age 55 in men and age 65 in women is

also a risk factor. The more family members with CHD, the more elevated the risk.

Attention to family history of other CVD such as stroke and diabetes is also important.

Personal history of cardiovascular disease: Since atherosclerosis affects arteries

beyond the coronaries, diseases of other blood vessels like stroke, peripheral artery

disease (narrowing of blood vessels in the limbs), or renal artery disease (narrowing of

renal vessels) all increase CHD risk.

Modifiable Risk Factors

The following are the risk factors for CHD that one can change, control, or modify. In the

Philippines, initiatives have been implemented to address each of these risk factors, with varying

success levels.

Cigarette Smoking: Cigarette smoking is a significant risk factor for CHD because it

decreases HDL cholesterol levels ("good” cholesterol), damages the lining of the arteries,
16
and promotes atherosclerosis and blood clot formation by promoting the stickiness or

aggregation of platelets.

Smoking also contributes to arrhythmias, cancers, and COPD. Second-hand smoke is also

a risk. If one stops smoking, their CHD risk can dramatically decrease by 50% within

even a year of quitting. Smoking is common in the Philippines, with 22.7% of the

population smoking tobacco. Vaping (e-cigarettes) use is increasingly used by the

younger population as well. The long-term effects of vaping on heart health are still

unclear. Many adults and children are exposed to second-hand smoke in the workplace, in

public areas, and at home. Approximately 110,000 Filipinos die yearly from

tobacco-related diseases (Campaign for Tobacco-Free Kids, 2020). Several initiatives

have been taken to address this smoking epidemic, including the signing of Executive

Order 26 in 2017 by President Rodrigo Duterte of the Philippines. This order bans

smoking in all public places in the Philippines, including schools, medical practices,

government facilities, food service areas, public transportation, and more.

Additionally in 2012, the Philippines government passed the "Sin Tax," which increased

the tax on tobacco from 2.72 PHP (Philippine Peso) to 30 PHP (Campaign for

Tobacco-Free Kids, 2017). By 2017, the average price per pack of cigarettes more than

doubled, and the number of adult Filipino smokers decreased from 28.3% in 2009 to

22.7% in 2015. More recently, the Philippines branch of the international company

Johnson & Johnson has partnered with the Philippines College of Chest Physicians to

provide quitting assistance and education to Filipino smokers. These services will train

healthcare providers on how to treat smokers who decide to quit smoking through

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educational smoking cessation programs. Such a program, a comprehensive webinar, can

be accessed here:

https://www.facebook.com/watch/live/?ref=watch_permalink&v=515741793624467

This will serve as a helpful resource to Filipino smokers, in addition to the already

available Department of Health mobile hotline that provides professional help, free

educational materials, and nicotine replacement therapy products as well as initiatives by

the Philippine College of Physicians and the Philippine Heart Association (Manila

Bulletin, 2021).

Hypertension: High blood pressure (BP), or hypertension, is another risk factor for CHD

because it damages blood vessels, setting the stage for atherosclerosis. Hypertension

often does not present symptomatically and can therefore remain undetected while

causing changes in the blood vessels ("silent killer") unless people regularly check their

BP. Adults should check their BP regularly by age 18 or earlier if they have a family

history of hypertension or other risk factors, and then yearly after 40 or more frequently if

their BP is elevated. The earlier the diagnosis, the better it can be treated and controlled

before further damage occurs in blood vessels. Lowering BP decreases the risks of CHD,

heart attack, stroke, heart failure, and kidney disease.

Table 5

Classification of blood pressure category per different professional organizations

Stages ACC/AHA ESC/ESH ISH PHA/PSH

Normal <120/<80 120-129/80-84 <130/<85 <120/<80

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Elevated 120-129/<80 130-139/85-89 130-139/85-89 120-129/80-89

Stage 1 130-139/80-89 140-159/90-99 140-159/90-99 140-159/90-99

Stage 2 ≥140/ ≥90 160-179/100-109 ≥160/ ≥100 160-179/100-109

Hypertensive >180/>120 ≥180/≥110 ≥180/≥110 ≥180/≥110

crisis

Acronyms: ACC/AHA = American College of Cardiology/American Heart Association,

ESC/ESH = European Society of Cardiology/European Society of Hypertension, ISH =
International Society of Hypertension, PHA/PSH = Philippines Heart of
Association/Philippines Society of Hypertension

In 2017, the American Heart Association announced new blood pressure guidelines to

encourage earlier hypertension detection and prevention. A BP of 121-129/71-80 mmHg

is now considered elevated. A BP above 130/80 mmHg is now considered hypertension

and lifestyle modification is recommended as an early intervention. However, the

European Society of Cardiology and Hypertension, the International Society of

Hypertension, and the Philippine Society of Hypertension regard 140/90 mmHg and

above as hypertension. BP readings may vary based on whether they are taken in the

clinic, office or at home. BP readings may also vary with the time of day they are taken,

influenced by caffeine and salt intake, stress, anxiety etc. Therefore, it is crucial to have

several data points. As BP increases, especially in the presence of other risk factors such

as diabetes, smoking, kidney disease, heart disease, or stroke, the more aggressive control

of BP is indicated. Lifestyle modifications like increasing physical activity, smoking

cessation, and dietary changes (decreasing salt intake and alcohol, increasing fruits,

vegetables, and fiber) are recommended as early treatment for elevated BP or Stage 1

19
hypertension. These lifestyle changes help enhance pharmacologic intervention to control

BP.

Hypertension in the Philippines continues to rise. A recently reported study by the

Philippine Heart Association found hypertension in 38.6% of the hospitalized Filipino

population. However, this statistic may be a major underestimation as many Filipinos are

not seen by medical practitioners. It is thought that the number of individuals with

hypertension may actually be higher in the adult Filipino population (possibly 45-50% of

the adult population) since the threshold of hypertension was changed in 2017.

Few people in the Philippines have their own BP machines or have access to clinics

where BP is routinely checked. It is an important public health measure to have

accessible kiosks or clinics to check people's BP routinely. To promote awareness and

education on such a prevalent issue, the Philippine Society of Hypertension, the

Philippine Council for Health Research and Development, the Philippines Department of

Health, and the International Society of Hypertension celebrate May as "Hypertension

National Awareness Month." An argument can be made that hypertension awareness

should be stressed each time any patient is seen.

Abnormal Levels of Blood Lipids: Cholesterol and triglycerides (types of fats) are

carried through the bloodstream on proteins called lipoproteins. Two specific lipoproteins

that transport blood cholesterol from the liver to the tissues are low-density lipoprotein

(LDL) and high-density lipoprotein (HDL). If one has elevated blood levels of total

cholesterol, LDL, small dense LDL particles and triglycerides or low HDL levels, the risk

for CHD increases. High levels of other blood cholesterol such as lipoprotein (a) (a
20
modified LDL particle) and apolipoprotein B (the main component of VLDL and LDL),

correspond to high LDL and VLDL, have also been linked to an increased risk of a heart

attack and stroke.

Elevated total cholesterol and LDL levels increase the likelihood that cholesterol will be

deposited within the artery walls, thus making people more susceptible to CHD. For

primary prevention (no history of CHD), LDL should be below 130 mg/dL but above 100

mg/dL for those with diabetes. For secondary prevention (history of CHD), LDL should

be below 70 mg/dL but above 55 mg/dL for those with severe atherosclerotic vascular

disease. However, not all cholesterol is harmful or increases CHD risk. HDL cholesterol

is often called "good” cholesterol because it transports fat molecules out of the arterial

walls and reduces macrophage accumulation, thus helping prevent or regress

atherosclerosis. Therefore, HDL is known to be protective against CHD.

During physical activity, blood flow to the heart is crucial. High levels of triglycerides

interfere with needed coronary dilatation through their association with atherogenic

particles that lead to the thickening of the arterial walls (arteriosclerosis) (Talayero and

Sacks, 2012). Normal triglyceride levels are below 150 mg/dL, and a level below 100

mg/dL is desirable. High triglycerides pose a greater risk in women than in men, and the

risk of CHD is even higher if a person also has low levels of HDL, high levels of LDL,

hypertension, obesity or high insulin levels, or the so called “metabolic syndrome”. In

people with high levels of triglycerides, one should look for secondary causes like

uncontrolled diabetes, metabolic syndrome, alcoholism, obesity, hypothyroidism and a

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high carbohydrate diet. Medications like estrogens, progestins, diuretics, retinoids,

steroids, some HIV medications, and immunosuppressants can also increase triglycerides.

In the Philippines, there are high rates of dyslipidemias. In 2013, the Philippines'

National Nutrition and Health Survey found that 72% of adults 20 years old and older

had one or more abnormal lipid levels. Specifically, approximately 47% had borderline to

high total cholesterol, 47% had borderline to high LDL, 71% had low HDL, and 39% had

increased triglyceride content (Lin et al., 2018). Efforts to decrease dyslipidemia in

Filipinos include the publication of the Executive Summary of the 2020 Clinical Practice

Guidelines for the Management of Dyslipidemia in the Philippines, in which medical

experts list holistic, non-pharmacological, and pharmacological treatment

recommendations (Gonzalez-Santos et al., 2020).

Obesity: Obesity is an escalating epidemic, defined as a body mass index (BMI) ≥ 30;

overweight is defined as a BMI ≥ 25. BMI is calculated by dividing weight in pounds by

height in inches squared and multiplying by 703. In Asians, a BMI of 23 or greater is

associated with an increased risk of CHD and diabetes.

A better measure of risk for CHD is waist circumference. The INTERHEART study

showed that the waist-hip ratio correlates better than BMI for risk for myocardial

infarction (Schneider et al., 2006). Waist circumference is measured by placing a tape

measure around the waist just above the hip bone at the level of the umbilicus.

Abdominal obesity increases CHD risk and has been linked to high troponins and risk for

heart failure (Journal of the American College of Cardiology: Heart failure). Abdominal

obesity is defined as a waist circumference of above 35 inches in women and above 40

22
inches in men. For Southeast Asians, the cut-off for men is 35 inches and 30 inches for

women (International Diabetes Federation). People with insulin resistance and large

abdominal circumference are more predisposed to developing diabetes, which is often

accompanied by high triglycerides and low HDL, further increasing the risk for CHD.

Excess weight around the waist and abdomen is a marker of visceral adiposity and is

associated with insulin resistance. Visceral adiposity can be better evaluated with a CT

scan or ultrasound.

Obesity in the Philippines has been steadily increasing, with 6.9% of all adults in 2015

and 9.3% of all adults in 2019 being obese (Global Obesity Conservatory, 2021). The

Philippines was given a national obesity risk score of 6/10 by the Global Obesity

Observatory, indicating moderate risk nationally. Some programs tackle the growing

obesity crisis, including the Philippine Plan of Action For Nutrition 2017-2022 by the

Philippines Department of Health. This six-year plan includes twelve programs with eight

nutrition-specific programs, three enabling support programs, and one nutrition-sensitive

program designed to enact better nutritional outcomes nationally.

Metabolic syndrome: Metabolic syndrome (MS), or syndrome X, initially coined by

Gerald Reaven at Stanford University, is defined by an cluster of abnormalities that

includes abdominal obesity (excess fat in the stomach area), a high triglyceride level, a

low HDL cholesterol level, high blood pressure, insulin resistance and high fasting blood

sugar. The X in syndrome X refers to the unknown significance of insulin resistance.

These conditions are associated with an increased risk of CHD, and a longitudinal clinical

study in the Philippines observed an overall prevalence of metabolic syndrome in 51% of

23
1367 adult patient participants (Mata and Jasul, 2017). Lifestyle changes like exercise,

weight loss, a high fiber diet, a low-fat diet, and control of other risk factors like high

cholesterol, high BP, and high glucose can significantly prevent MS.

Diabetes Mellitus: Diabetes mellitus (diabetes) is a disease in which glucose levels in

the blood are elevated due to the inability of the pancreas to secrete enough insulin or the

inability of the body to dispose of glucose due to an inappropriate response to insulin

(insulin resistance). Fasting blood glucose of 100-125 mg/dL indicates pre-diabetes and

126 mg/dL or higher indicates diabetes (CDC, 2019). There are multiple types of

diabetes. Type 1 diabetes, formerly called insulin-dependent diabetes, is characterized by

the failure of the pancreas to secrete insulin. Type 2 diabetes, formerly called

non-insulin-dependent diabetes, is the most common type of diabetes characterized by

insufficient insulin production by the pancreas or cells that are refractory to the effects of

insulin (insulin resistance). Once uncommon in adolescents and children, Type 2 diabetes

is now emerging in younger age groups, primarily driven by increasing childhood

obesity. About 80-90% of people with Type 2 diabetes are obese. Other, less common

types of diabetes which will not be discussed here.

Several CHD risk factors, including abnormal cholesterol levels and high blood pressure,

are common in individuals with diabetes. Risk factors for diabetes include a family

history of diabetes, obesity, gestational diabetes, polycystic ovary syndrome (PCOS),

aging, race, ethnicity, and metabolic syndrome. All of these can compound the risk of

CHD. Diabetes can be prevented by lifestyle changes, such as better nutrition and

24
increased physical activity, and by actively monitoring glucose blood levels if a person is

at risk for diabetes.

Diabetes is advancing in ranking to the top five leading causes of death in the Philippines.

In 2020 in the Philippines, 6.3% of adults had diabetes, or 3,993,300 cases (International

Diabetes Federation, 2020). The Philippine Center for Diabetes Education Foundation is

one organization that has several initiatives to address the growing number of Filipinos

with diabetes. Such programs include an intensive diabetes training course for healthcare

providers, an annual diabetes awareness week, and Camp COPE (Children Overcoming

Diabetes Problems Everywhere), a summer camp for children with Type 1 diabetes.

Sleep Apnea: Sleep apnea is a disorder in which one's breathing is abnormal during sleep

and is characterized by decreased oxygen levels in the blood. A person with sleep apnea

can experience abrupt stopping and starting of breathing during sleep and may also

experience snoring, choking, or gasping during sleep, morning headaches, awakening

with a dry mouth, tiredness, irritability, and difficulty focusing. Sleep apnea is related to

several CHD risk factors, including hypertension and abnormal heart rhythms. A global

data analysis study in 2020 found that approximately 16 million Filipinos (6.25% of the

total population, which is an underestimate if age is adjusted) aged 39-60 years old

experience sleep apnea based on an apnea-hypopnea index (AHI) cut-off value of five or

more events per hour of sleep (Benjafield et al., 2019). However, there are currently no

prevalent studies on sleep apnea in the Philippines, and awareness is low; sleep apnea

may be underdiagnosed in the Philippines. One of the few sleep apnea campaigns in the

Philippines is the Sleep Apnea Forum, hosted by the Sleep Society of the Philippines and

25
Centuria Medical Makati in 2017. This forum consisted of lectures and treatment

demonstrations to educate healthcare providers on sleep apnea (Patasongkram, 2017).

Physical inactivity: Physical inactivity can lead to other CHD risk factors, such as

hypertension, abnormal blood lipid levels, obesity, and the risk of subsequent conditions

such as a heart attack. Generally, physical activity can decrease CHD and help one

maintain a healthy lifestyle. The indigenous population in the Philippines is leaner since

they walk more and are generally active in farming and hunting. However, in urban poor

and affluent areas, people are more sedentary. In 2019, the WHO found that the

Philippines had an overall physical inactivity prevalence of 93.4%. Filipino youth have

been particularly noted to be highly inactive, and in a 2016 study, Filipino adolescents

were ranked as the second most physically inactive teens in the world (World Health

Organization, 2019).

As a result, obesity in young people is rising in the Philippines. Campaigns to promote

physical activity have been implemented, including programs that have shifted to

accommodate exercise at home in response to the COVID-19 pandemic. In May 2020,

the Philippines Department of Health and the Philippines Sports Commission (PSC)

launched "Wais Papawis" (Wise Exercises), an educational campaign that includes

readily accessible at-home exercises. Similarly, in 2021, the PSC announced: "Igalaw

Galaw Ating Katawan" (Move Your Body), a solo dance contest to encourage exercise

through art.

Mental health: Mental health issues, particularly stress, anxiety, and depression, can

contribute significantly to CHD. Stress can directly lead to CHD and subsequently
26
unstable angina or heart attack through the body's physiological responses to stress.

When stressed, the body releases hormones such as cortisol and epinephrine that increase

blood pressure and heart rate and cause narrowing or spasm of the coronary arteries,

promoting CHD. Long-term stress has also been linked to inflammation, which can also

predict CHD. Specifically, significant biomarkers of systemic inflammation, including

IL-6 and CRP, are elevated in different life stages and are thought to be signs of

atherosclerosis (Liu et al., 2017).

Depression and its pharmacologic treatment are associated with an increased risk of

CHD. Directly, depression can cause decreased parasympathetic or increased sympathetic

autonomic nervous activity, promoting increased blood pressure and blood cholesterol

levels, and can cause myocardial ischemia, ventricular tachycardia, ventricular

fibrillation, or heart attack (Skala et al., 2006). Indirectly, depression can lead to

decreased adherence or follow-up to medications and less engagement with healthy

lifestyle habits, potentially increasing CHD risk. Generally, depression and anxiety have

been associated with a 25% increased risk of heart disease.

Type A Behavior Pattern (TABP) is a characteristic term for individuals who are

ambitious, competitive, anxious, highly focused, or impatient. In the 1950s, American

cardiologists Meyer Friedman and Ray Rosenman presented the idea that TABP is related

to increased risk for CHD (Petticrew et al., 2012). Conflicting studies on this relationship

show a lack of significant association, leading to ambiguity about this theory.

Specifically, results from the Western Collaborative Group Study in 1970 in the GAZEL

27
(French men) and JHPC (Japanese individuals) cohorts showed that TABP is not a

predictive risk factor for French or Japanese individuals.

Mental illness ranks as the third most common disability in the Philippines, with

approximately 6 million Filipinos suffering from depression and/or anxiety (Martinez et

al., 2020). Despite the high prevalence, help-seeking attitudes toward mental illness

amongst Filipinos and support from the Philippine government remain low.

Approximately 10.72% of Filipinos demonstrate help-seeking behavior, and only 0.22%

of total health expenditures are spent on mental health by the Philippines government.

This could be attributed to the Filipino cultural taboo around mental illness and the fact

that many Filipinos see mental illness as a sign of weakness or contradictory to the

preferred happy mindset. However, some mental services include free or discounted

telemedicine services, hotlines, clinics, foundations, and various support groups. The

Philippines also recently passed its first Mental Health Act to improve mental health

service access (Lally et al., 2019).

Air pollution: Air pollution can increase CHD risk, particularly if subjected to it

long-term and with simultaneous experience of other CHD risk factors. Air pollution

cardiotoxicity can lead to increased blood pressure, blood clotting, and atherosclerosis,

leading to CHD (Simkhovich et al., 2009). Avoiding time outside where air pollution is

high or wearing a recommended face mask can help reduce CHD risk. In 2018, 43.3 out

of 100,000 deaths in the Philippines were air pollution-related (ABS-CBN News,

Philippines, 2020). In 2020, the Philippines had an average Air Quality Index (AQI)

ranking of 52, 1.3 times the WHO recommended AQI value (IQAir, 2021). Little

28
 legislative action has been taken to combat increasing air pollution levels, but some local

commitments have been made. Private organizations like ABS-CBN, under the

leadership of Gina Lopez, fought to clean the environment by taking on negative

contributions from the mining, fishing and home-building industries. Additionally, in

2019, Manila City, the capital of the Philippines, became a part of the BreatheLife

campaign, a program that promotes public health and climate change education to

decrease air pollution (BreatheLife, 2020).

Despite such efforts, many factors continue to contribute to the low air quality in the

Philippines, such as the sale of single cigarettes and pollution from the public

transportation system like jeepneys and buses. Local salespersons and stores commonly

sell single cigarettes to all, including minors (Villamor, 2017). These sales make the

acquisition of cigarettes and smoking very accessible, thus constantly increasing air

pollution levels. Additionally, the growing use of motor vehicles has heavily contributed

to many pollutants. Jeepneys are the Philippines' most popular form of public

transportation, with approximately 180,000-270,000 jeepneys actively in use

(Westerman, 2018). They are also known as intense polluters, and studies have shown

that diesel-based jeepneys have been responsible for 15% of air toxins in Metro Manila.

Efforts are ongoing to decrease the number of jeepneys in Metro Manila.

Prevention of CHD

Prevention is especially crucial for people at risk for CHD. There are several methods to prevent

CHD.

29
Awareness of Risk: An individual can use a calculator to estimate CHD risk in the next 10 years ,

which can guide risk reduction. However, a specific estimate has not been made for the Filipino

population. Conducting regular screenings for BP, blood sugar and cholesterol in people at risk

for CVD diseases can improve awareness.

Healthy Diet: Adoption of a healthy diet can lower CHD risk. A healthy diet, which should

include less processed foods, refined carbohydrates, saturated and trans fats, and sweetened

beverages should be at the forefront. It should contain increased monounsaturated and

polyunsaturated fats and omega-3 fatty acids found in fatty fish like herring, sardines, and

salmon. The value of plant-based foods, which are rich in complex carbohydrates and fiber,

including fruits, vegetables, whole grains, and proteins found in plants, fish, and lean meat

should be emphasized.

Socialization in Filipino culture is primarily organized around food and can symbolize love,

friendship, and respect. The diet of Filipino adults mainly consists of refined rice, pork, fats, oils,

chicken, and bread with a low intake of vegetables, fruits, and dairy. Fried food, salty seasonings

such as "patis” (fish sauce, "bagoong” (shrimp paste) , and "toyo” (soy sauce), preserved foods

with high salt content due to a lack of refrigeration, processed foods, and regular soda are also

highly consumed. In a recent study observing food intake in Filipino adults, nutrient inadequacy

was high, and very few nutrient-dense foods were consumed (Agdeppa and Custodio, 2020).

These nutrition inadequacies are often found in older adults, females, and people of lower

socioeconomic status. Incorporating low-cost, healthy recipes tailored to the Filipino diet is

highly desirable to help mitigate the risk of CHD.

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Physical Activity: Regular exercise has shown benefits in controlling weight, raising HDL

cholesterol, reducing BP, and relieving stress. The American Heart Association recommends that

adults engage in at least 30 minutes of moderate-intensity aerobic exercise with a heart rate of

120 bpm five days a week. Muscle-strengthening activities should also be incorporated on

nonconsecutive days at least twice a week. Common exercises aligned with the Filipino culture

can be incorporated to meet these recommended guidelines. Physical activities like dancing,

team sports, and household chores are suitable for moving, stretching, and burning calories. For

example, sweeping, mopping, cleaning furniture, washing the dishes, and doing the laundry can

help strengthen bones, joints, and muscles. Even carrying grocery bags from the market is a form

of resistance exercise (Rappler, 2021). Education on the necessity for physical activity and

possible exercises should start in a child's primary school education and at home to help combat

childhood and youth obesity which is rising in the Philippines.

Stress Management: Stress reduction is also important for cardiac health. Finding effective

coping techniques and activities such as regular aerobic exercise, yoga, or meditation, can help

an individual manage stress. Historically there has long been a stigma on mental health in the

Philippines. Increased awareness of the importance of mental health can better encourage

Filipinos to address their own mental health positively.

Quit Smoking: Quitting smoking has many positive benefits for heart health, even for patients

who have already experienced CHD or a subsequent condition. Smoking encompasses cigarettes,

tobacco chewing, e-cigarettes, or vaping. Smoking education, counseling, support groups,

hotlines, and making a plan are some effective ways to guide smoking cessation. Nicotine

replacement and prescriptions like varenicline (Chantix) and bupropion (Zyban), which can

31
reduce craving and withdrawal symptoms, are not highly prescribed in the Philippines and are

not readily available. Counseling to stop smoking is also not a usual part of a doctor-patient

encounter. However, in the Philippines, the promotion of governmental protocols against

smoking, such as Executive Order 26 and the "sin tax law," or legislature that raises taxes on

alcohol and tobacco products have helped reduce the incidence of bad habits after just a few

years of implementation.

Weight: Losing weight and maintaining it at a healthy level is highly effective in lowering

triglyceride levels, raising HDL cholesterol, lowering blood pressure, and preventing and treating

Type 2 diabetes. Historically in the Philippines, being overweight is a sign of wealth and health.

It is changing as more people are now aware of the benefits of limiting weight gain.

Diagnosis of CHD

A careful history taken by a physician is essential. This information should include a risk

assessment that evaluates medical history, family history of hypertension, stroke, heart attacks,

diabetes, hyperlipidemia, and social history, including alcohol, smoking, recreational drug use,

lifestyle, physical activity, and diet profile. The physician will then ask about symptoms such as

fatigue, shortness of breath with exertion, chest pain, palpitations, and other cardiac symptoms

like swelling of the legs, nausea, indigestion, etc. If appropriate, many diagnostic tools are at a

physician's disposal, including blood tests for sugar, cholesterol, and kidney function, ECG and

cardiac stress tests, and imaging tests.

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Blood Tests

Blood Chemistry Test: A blood chemistry test is a blood test that measures the amount

of various types of chemicals in the blood. This test often checks electrolytes and can

detect abnormalities contributing to some heart rate irregularities or arrhythmias. A

specific type of blood chemistry test, a creatinine test, measures how well the kidney

filters the blood. Creatinine tests are also important since kidney dysfunction is another

risk factor for CHD.

Complete Blood Count (CBC): A complete blood count is a common blood test that

measures the number of cells in the blood, including platelets, red blood cells, and white

blood cells. CBC can detect a wide range of conditions and provide important health

information. For example, CBC determines if one has anemia, which may contribute to

fatigue and shortness of breath by decreasing the oxygen-carrying capacity of the blood.

Cholesterol Test ("Lipid Profile"): A cholesterol test, or lipid profile, is a blood test

that measures the number of various types of fats in the blood. This test often checks for

total cholesterol, high-density lipoprotein (HDL) “good” cholesterol, low-density

lipoprotein (LDL) “bad” cholesterol, triglycerides, and other fat types. Cholesterol tests

are important for assessing CHD risk since abnormal levels are one of the major risk

factors for myocardial infarction globally.

Thyroid Tests: Thyroid blood tests measure the amount of thyroid hormones in the

blood. These tests often check for hormones such as thyroid-stimulating hormones (TSH)

33
 and thyroid hormones T3 and T4. Thyroid tests may help evaluate causes of palpitations

and arrhythmias or CHD symptoms like fatigue or shortness of breath.

Stress Tests

Close monitoring during stress tests is conducted since they carry a small risk of heart attack or

cardiac arrest, especially in individuals with advanced CHD.

Electrocardiogram (ECG): An ECG records the electrical activity of the heart. It can be

done while at rest or as part of a cardiac exercise stress test. It is a painless procedure

where sensors called electrodes are placed on the arms, legs, and chest to record the

electrical heart rhythm. It can help diagnose arrhythmias, irregularities of the heartbeats,

heart attacks, or any signs of enlargement like hypertrophy or heart block. It is limited, as

it is done at rest, so it may be difficult to evaluate coronary blood flow in an exercising

state when the demand on the heart increases. Therefore, an ECG is also done during

stress tests. In some stress tests where patients cannot exercise, medications or

radioisotopes are administered to the patient to add to the diagnostic accuracy of the tests.

Exercise Stress Test: A standard exercise stress test requires a patient to walk on a

treadmill or pedal a stationary bicycle while an ECG records electrical signals from the

heart. This test can help detect CHD by determining if significant blockages affect blood

flow in the coronary arteries during physical activity. Speed and incline are adjusted to at

least 85% of the patient's maximum target heart rate, which can be calculated by

subtracting their age from 220. Tests may be stopped when the maximum target heart rate

is achieved, or if the patient experiences chest pain, fatigue, shortness of breath,

34
dizziness, or significantly irregular heartbeat. Accuracy can be improved if done

alongside myocardial perfusion imaging or echocardiography before and immediately

after exercise.

Nuclear Medicine Stress Test: If a standard stress test shows no apparent abnormalities

despite symptoms suggesting CHD, a nuclear medicine imaging stress test can be

additionally done to pinpoint which heart regions have compromised blood flow. The

nuclear medicine stress test can add to the accuracy of the standard exercise stress test by

up to 90% versus 75-80% for a stress test without imaging. It follows the same procedure

as a standard stress test, but when a target heart rate is reached, a radioactive tracer

(technetium) is injected into a vein in the arm. A special camera detects the radioactive

tracer as it travels to the heart via the bloodstream. Areas of the heart that have narrowed

arteries will have less radioactive material. The test can be repeated at rest on the same

day, and if flow normalizes at rest, that suggests compromised blood flow to that segment

of the heart with stress. Some clinicians will select an exercise echocardiogram to

decrease exposure to radioactive substances.

Pharmacologic Stress Test: If a patient is unable to walk on a treadmill or pedal a

bicycle (for reasons including musculoskeletal disability, neurodegenerative disorders

like Parkinsons or Multiple Sclerosis, deconditioning, or being frail), a pharmacologic

stress test can be done instead of the exercise stress tests. Dobutamine, a drug that can

simulate the effects of physical exercise, is injected into a vein in the arm, and the

electrical signals can be monitored while the patient remains seated or lying down. Some

35
 nausea or shortness of breath may be experienced. Other drugs, such as regadenoson, a

coronary vasodilator, are also useful for radionuclide myocardial perfusion imaging.

Resting and Exercise Echocardiography: Echocardiography is another mode of

imaging that takes live images of the heart while the patient is at rest and during the peak

of exercise. A transducer, a tool that reflects sound waves, is pressed against the chest

and abdomen of a patient lying down on their left side. This data can indicate abnormal

heart function, valvular abnormalities, heart defects, and fluid around the sac of the heart.

Anatomic Assessments of the Heart Arteries

Coronary Artery Calcium Scans (CAC): Coronary artery calcium scan measures the

quantity of calcium in the coronary arteries using a rapid CT imaging technique. Calcium

is typically a component of calcified plaques, and calcium presence is abnormal in

healthy arteries. In less than 10 minutes, a CT scan of a patient lying down is taken, and a

computer generates the calcium score. Calcium in the coronary arteries will appear as

white areas on the CT scan. Scores are calculated from 0 to thousands. CAC is the

preferable method of detecting CHD in patients who do not have CHD symptoms but are

at intermediate risk. People with a CAC score of <100 may not benefit from statins as

much as those with at least 100. A study found that the higher the CAC scores, the higher

the risk associated with sudden cardiac death.

Coronary Angiography: Coronary angiography takes images of the coronary arteries to

detect blockages. A contrast substance is injected into a catheter placed into an artery.

The X-ray machine rapidly takes a series of images (angiograms), enabling the

36
cardiologist to see the blood flow of that artery. Blockages in the coronary arteries can

then be identified. Coronary angiography is the preferred method for evaluating

blockages in the coronary arteries in patients with symptoms. In men, this test

specifically correlates well with symptoms. In women, results of the coronary angiogram

may be misleading as women tend to have involvement in the smaller vessels. Coronary

angiography is a preferred diagnostic (to diagnose) procedure to determine blockage

because it can also be used as a therapeutic procedure to relieve the occlusion.

Computed Tomography Angiography (CTA): Computed tomography angiography is

non-invasive angiography where 3-D images of the coronary arteries are taken. A

contrast substance is injected into a peripheral vein to allow the CT machine to capture

images of the blood flow through the coronary arteries. CTA is a method for detecting

blockages in the coronary arteries. It may help eliminate the possibility of CHD in low or

moderate-risk patients following inconclusive stress test results. CTA helps rule out heart

attacks in the ER in patients with symptoms when an ECG and blood test results are

inconclusive. American guidelines have recommended using CTA to exclude

atherosclerotic plaque and obstructive CAD in patients complaining of chest pain with

now known CHD. Disadvantages of CTA are exposure to radioactive substances and

contrast dye (problematic in patients with kidney abnormalities) and the inability to treat

the observed blockage. Treatment of such blockage can be done during coronary

angiography which is advantageous for both diagnostic and therapeutic relief of the

occlusion.

37
 Magnetic Resonance Imaging (MRI): Magnetic resonance imaging takes detailed

images of the heart using powerful magnets and radiofrequency waves. It can detect the

size and thickness of the heart's chambers and determine heart function, heart damage,

aneurysms, and blockage of coronary arteries. An advantage is the lack of exposure to

radiation and contrast dye. A drawback is the inability to use this in patients with

implanted pacemakers, defibrillators, and other metallic devices.

Treatment of CHD

There are several types of treatment for CHD. Medications can work effectively however, the

severity of the condition may require interventions, such as angioplasty (with or without

stenting) or coronary artery bypass graft surgery. These interventions can result in long-lasting

effects and better quality of life if healthier lifestyle changes are adopted as well. Treatment also

involves managing coexisting diseases that may multiply the effect of CHD and consequential

conditions of CHD, including angina pectoris, arrhythmias, heart failure, and myocardial

infarction.

Medications

There are four categories of medications to prevent and treat CHD. These include antiplatelet,

anticoagulant, blood-pressure-lowering, and lipid-lowering medications. Lifestyle modification

augments the effects of these medications.

Antiplatelet Medications: Antiplatelet drugs are prescribed to reduce the risk of blood

clots. They work by preventing platelets, a blood component, from clumping together to

form a blood clot that can rapidly result in a heart attack or stroke. Common antiplatelet

38
medications are aspirin and clopidogrel (Plavix). Aspirin rapidly reaches peak activity in

30-40 minutes and can be bought over-the-counter. Clopidogrel is more expensive but

less likely to produce gastrointestinal symptoms and complications. There are also

relatively newer antiplatelet medications like ticagrelor (Brilinta) and prasugrel (Effient),

that are used in combination with other antiplatelet medication with drug-eluting stents.

The use of two antiplatelet drugs can result in an increased risk of bleeding. These are

commonly used after coronary stents.

Anticoagulant Medications: Anticoagulant medications also reduce the risk of blood

clots by interfering with fibrin formation. The traditional anticoagulants are warfarin,

unfractionated heparin, and low-molecular-weight heparin. More recently marketed

anticoagulants, or direct-acting oral anticoagulants referred to as NOAC (novel oral

anticoagulants) include dabigatran, rivaroxaban, apixaban and edoxaban. These drugs

decrease the risk of stroke in patients with atrial fibrillation or are used in treating

embolisms.

Blood Pressure-Lowering Medications: When a patient's blood pressure is 140/90

mmHg or higher, a physician will most likely prescribe medications to lower it in

addition to lifestyle modification. Studies have found that lowering systolic blood

pressure to around 120 mmHg systolic and 80 mmHg diastolic was associated with fewer

heart attacks, strokes, and deaths compared to a systolic blood pressure of about 135

mmHg to 140 mmHg. There are several classes of blood pressure-lowering medications:

diuretics, beta-blockers, renin-angiotensin-aldosterone-system blockers, namely

angiotensin-converting enzyme (ACE) inhibitors, and angiotensin II receptor blockers

39
(ARBs), calcium channel blockers, and alpha-2 agonists like clonidine and

alpha-methyldopa. The generic names for some classes of blood pressure medications

end as follows: "-pril" like enalapril for ACE inhibitors, "-sartan" like losartan for ARBs,

"-olol" like metoprolol for beta-blockers, and "-pine" like amlodipine for calcium channel

blockers. Ace inhibitors and Angiotensin receptor blockers have kidney-protecting

qualities and therefore are preferred in patients with hypertension and diabetes. Currently,

endothelin receptor antagonists, which are vasodilators like Bosentan, Ambrisentan, and

Macitentan, are emerging for the treatment of hypertension but are very expensive.

Lipid-Lowering Medications: Lipid-lowering medications reduce LDL cholesterol, the

primary lipid-lowering medications are statin drugs. Statins work by blocking the action

of an enzyme required for the liver to produce cholesterol. As a consequence of blocking

this action, the liver makes less cholesterol and more LDL receptors, or receptors that

remove LDL from the blood. Statins include: simvastatin (Zocor), atorvastatin (Lipitor),

pravastatin (Pravachol), rosuvastatin (Crestor), fluvastatin (Lescol, Lescol XL), lovastatin

(Altoprev), and pitavastatin (Livalo). In the Philippines, simvastatin, atorvastatin, and

rosuvastatin are most commonly used. Aggressive therapy may be needed beyond statins

when LDL is still above 70 mg/dL in high-risk patients or above 55 mg/dL in very

high-risk patients. Such therapies are now available such as ezetimibe (Zetia) and the

new, potent injectable Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors

such as evolocumab (Repatha) and alirocumab (Praluent).

40
Revascularization Treatments

Revascularization of coronary arteries with blockages improves blood supply to the heart.

Revascularization is considered if medications do not control a patient's symptoms. It is also

considered during a heart attack to salvage the myocardium. There are two approaches:

percutaneous coronary intervention (PCI), done by interventional cardiologists, which includes

balloon angioplasty with or without stenting, and surgical coronary artery bypass graft surgery,

which is done by cardiovascular surgeons. Lifestyle changes and medications, which are used

prior to these vascular intervention procedures are essential after these procedures as they do not

prevent the progression of atherosclerosis.

PCI - Balloon Angioplasty/Coronary stents: Angioplasty opens a clogged coronary

artery by widening the artery with a balloon on the tip of a catheter. The catheter is

inserted through the femoral artery or the radial artery. An angioplasty is not done in an

operating room but rather in a cardiac catheterization lab. The procedure can last between

thirty minutes to two hours, depending on the anatomy. An angioplasty is typically

combined with the insertion of a stent, which is a small, mesh-like tube. The stent is

placed where the plaque obstruction is. Some stents keep the artery open by releasing a

substance that will reduce or prevent injury reaction that produces re-stenosis or recurrent

obstruction.

41
Figure 3

Coronary artery stent (Johns Hopkins School of Medicine, n.d.)

Coronary Artery Bypass Graft Surgery: A cardiologist may determine that coronary

artery bypass graft surgery is better than PCI if the left main artery or multiple arteries

have significant blockages. The surgery involves rerouting blood around a blocked

coronary artery using a blood vessel harvested from elsewhere in the body. This blood

vessel is usually a vein harvested from the legs or an artery, such as the internal

mammary artery, from the chest. Arteries are preferred due to their durability, resulting in

a higher percentage of patency after several years compared to vein grafts. Bypass

surgery is more invasive than PCI, can take three to five hours in the operating room,

require general anesthesia and heart-lung bypass, a more extended hospital stay, and

several months of recovery.

42
 Figure 4

Coronary artery bypass graft surgery (Johns Hopkins School of Medicine, n.d.)

Bypass Surgery versus Angioplasty: Bypass surgery is considered the better option

than PCI when there is significant narrowing of the left main coronary artery or

narrowing of ostial or proximal segments of three or more vessels (diffuse coronary

artery disease), often seen in patients with diabetes or severe atherosclerosis.

Management of Consequences of CHD

Angina: Angina is chest pain or discomfort due to insufficient amount of blood being

delivered to the heart. Its description may be different between people and gender.

Nitrates (Isosorbide, nitroglycerine), beta-blockers (Metoprolol, Atenolol), and calcium

channel blockers (Diltiazem/Cardizem) are the three main types of drugs used to treat
43
angina. Newer medications include ranolazine. These medications decrease the heart's

demand for oxygen and increase its blood supply, which can help relieve angina.

Arrhythmias: Arrhythmias are irregular or abnormal heartbeats, also known as "skipped

beats or palpitations". Several groupings of antiarrhythmic drugs are used to treat

arrhythmias. These medications can help alleviate symptoms that may have manifested

from CHD or valvular heart disease, drug use (nicotine, stimulants, and other drug side

effects), thyroid dysfunction, electrolyte imbalance, or stress. Such symptoms include

palpitations, rapid or slow heartbeat, skipped beats, fatigue, syncope (loss of

consciousness), dizziness, shortness of breath, or chest pains. Antiarrhythmic drugs

include Class I drugs: flecainide and other less utilized medications such as quinidine,

procainamide, lidocaine, and mexiletine, that work on the myocardial cell’s sodium

channels. Class II drugs: beta-blockers, including metoprolol and carvedilol, inhibit the

sympathetic effect on the myocardial cells. Class III drugs: potassium channel blockers,

including amiodarone, dronedarone, and sotalol. Class IV drugs: calcium channel

blockers, including verapamil and diltiazem. Additional drugs include upstream target

modulators like ARBs, ACE inhibitors, endothelin antagonists, Omega 3 fatty acids, and

statins. Non-pharmacologic treatments are pacemakers, ICDs (implantable cardiac

defibrillators), or biventricular pacing devices. Treatment is typically guided by a

cardiologist or cardiac electrophysiologist and depends on symptoms and the presence or

absence of heart disease.

Heart Failure: Heart failure is the inability of the heart to pump sufficient amounts of

blood for the body's needs. It may be caused by CHD or other structural diseases of the

44
heart like valvular dysfunction, hypertrophy, infection like viral myocarditis or

cardiomyopathy, or drug toxicity. Symptoms are usually brought on by exertion, stress,

dietary indiscretion, or anxiety and are relieved by rest and pharmacologic intervention.

Several types of drugs are used to treat heart failure. These medications can help alleviate

symptoms such as shortness of breath, fatigue, decreased energy, cough, edema or

swelling, and wheezing. The medications can also reduce hospitalization and mortality.

Diuretics like furosemide (Lasix) decrease blood volume overload and relieves

congestion, ACE inhibitors like enalapril and captopril, ARBs (angiotensin receptor

blockers) like losartan, candesartan, valsartan, telmisartan, and combined angiotensin

receptor blocker valsartan and neprilysin receptor inhibitor sacubitril (ARNI), reduce

symptoms, hospitalization for heart failure, and mortality. Beta-blockers such as

metoprolol, carvedilol, bisoprolol, and nebivolol help the heart beat more slowly and less

forcefully by decreasing sympathetic stimulation. Slowing heart rate will allow more

filling of the ventricles. The new sodium-glucose Cotransporter-2 SGLT2 inhibitors

(dapagliflozin and empagliflozin) are diabetes medications found to reduce mortality,

cardiovascular events like heart failure, and kidney failure in patients with or without

diabetes. Vasodilators, such as hydralazine in combination with nitrates, may also treat

heart failure, especially in African Americans. Besides pharmacologic management, other

treatments include implantable cardioverter-defibrillators (to prevent sudden cardiac

death) and cardiac resynchronization therapy in patients with conduction abnormalities,

especially left bundle branch block, which can improve the left ventricular ejection

fraction.

45
Coronary Heart Disease Initiatives in the Philippines

Since 1973, February has been celebrated as Heart Month in the Philippines (TANGGAPAN NG

PANGULO NG PILIPINAS, 1973). During this month, the Department of Health (DOH) and the

Philippine Heart Association (PHA) implement various events across the country to promote

cardiovascular health and CHD awareness. The DOH campaigns with the slogan “Mahalin mo

ang Pusong nagmamahal” (Love the Heart that loves). This slogan aims to encourage people to

implement healthier lifestyle habits such as eating right, managing stress, avoiding alcohol,

maintaining a healthy weight, and quitting smoking. To educate on the goals of their Heart

Month slogan, specific initiatives hosted by the PHA and DOH include walkathons and other

public activities. These events also typically offer screening services such as ECG, blood

pressure, heart rate, and BMI monitoring so that individuals can better understand their heart

health. Additionally, in 2013, the DoH launched the Pilipinas Go4Health campaign (Randa,

2013). This project focused on four cornerstones: Go Smoke-Free, Go Slow sa Tagay (moderate

alcohol consumption), Go Sustansya (eat a nutritious and proper diet), and Go Sigla (exercise

more). The keyword "Go" repetition emphasized the importance of leading an active lifestyle.

Similarly, initiatives by the PHA include hosting an annual Heart Fair. Traditional Heart Fair

activities include Zumba dancing, lectures on healthier living, CPR demonstrations, and

interactive booths (Philippine Heart Association, 2015).

46
Figure 5

Department of Health Heart Month (Philippines Department of Health, 2018)

Local hospitals also host events during Heart Month. In February 2020, Green City Medical

Center in San Fernando held its Heart Month celebration. Like the DOH and PHA events, they

focused on raising awareness of heart disease through health screenings and lectures (GreenCity

Medical Center, 2020). Also, in 2020, the Maria Reyna Xavier University Hospital in Cagayan

de Oro celebrated Heart Month using the slogan "One Heart, One Nation, One Music." The

hospital offered 30% discounts on ECGs and had free lectures hosted by cardiology professionals

on various cardiac health topics (Maria Reyna-Xavier University Hospital, 2020).

Apart from the annual Heart Month celebrations, the Philippines actively works to address and

improve the cardiovascular health of its citizens. The Philippines is a part of the WHO HEARTS

project that aims to help countries improve CVD management through primary health care (NCD

Management Screening, Diagnosis and Treatment, 2018b). The HEARTS project guides health

authorities in the prevention, detection, and treatment of CVDs, identifying problems and

addressing barriers to care. For example, the project highlighted the irregular availability of NCD

medicine, particularly for CVDs, and inaccessible health supplies. It also underscored the limited

47
capacity of health workers to counsel patients and families on healthy life choices and how to

recover from a heart attack (World Health Organization, 2017).

ABC's for Global Health

ABC's for Global Health, a nonprofit organization, has several initiatives to educate and bring

awareness about CHD and its risk factors, prevention, and subsequent complications. For

example, ABC's for Global Health has conducted several studies on CHD and related conditions.

Most recently, projects include "The Effectiveness of Lifestyle with Diet and Physical Activity

Education Program Among Pre Hypertensives and Stage 1 Hypertensives in an Urban

Community Setting (ENLIGHTEN) Study'', which studied the efficacy of a monthly heart health

educational program. This program included materials on maintaining a healthy diet and

adequate physical activity to lower blood pressure. For six months, a control group and

intervention group were studied. The intervention group participated in the monthly educational

program. After six months, systolic blood pressure was significantly lower in the intervention

group than in the control group. Moving forward, similar educational programs could provide

low-cost, sustainable heart health intervention.

Additionally, the "Philippine Chronic Disease Prevention Project'' is an ongoing project studying

chronic disease prevention methods. Because pharmacological treatments are generally

expensive and inaccessible, practices for a healthy diet and regular exercise are promoted in this

study to specifically improve hypertension, a common risk factor for CHD. For a period of six

months, a group will be educated on hypertension, a healthy diet, and physical activity to learn

how these factors are related to improving chronic disease conditions. In the future, focusing on

48
the sustainability of such programs may provide improved health outcomes for those with

hypertension and even diabetes.

Presentations of similar projects by ABC's for Global Health include "If We Build It, Will They

Come? Deploying a Medical Mobile Clinic In The Philippines" at the 2015 Consortium of

Universities for Global Health (CUGH) convention in San Francisco (Figure 6). This project

detailed the deployment of mobile medical clinics in some of the Philippines' poorest and most

underserved communities. A sequel to this project, "We Built It And They Came" was presented

at the 2021 CUGH convention in Washington DC (Figure 7). This project described the

successful launch of mobile medical clinics in eighteen underserved communities in the

Philippines.

Figure 6

If We Build It, Will They Come?

49
Figure 7
We Built It And They Came

Figure 8

ABC's for Global Health Brochures and Infographics

50
In 2017, ABC's for Global Health worked on "doctorgram," a telemedicine pilot project by

Stanford Med Scholars that can extend care to people with limited access to care. This project

became instrumental during the COVID-19 pandemic, where telemedicine was the only available

healthcare resource for many people. DoctorGram is a digital app that can collect patient health

data and connect patients virtually with health care providers (Figure 9). This program was

piloted in 2017 by Stanford medical student Steve Ko to serve the indigenous populations.

Currently, ABC's for Global Health has four communities using telemedicine and also partners

with several medical schools for implementation. The vision is to expand the use of this

technology to reach out to more communities.

Figure 9

ABC's for Global Health DoctorGram

51
Conclusion

Coronary heart disease is the leading cause of death in the Philippines and globally. This white

paper aims to increase awareness of the causes, manifestations, risk factors, diagnosis and

prevention of CHD to improve outcomes through treatment and lifestyle modifications. Through

collaboration, education, and advocacy, we will decrease CHD's prevalence and its contributing

risk factors.

This white paper has resources for any reader, though specifically intended for patients with

CHD, treating physicians, and involved community partners. We hope that for patients with

CHD, this paper can serve as a general informational guide for personal use and to be shared

with their providers. Treating physicians then may use this paper as a guiding resource to provide

care. Furthermore, community partners in any capacity, including but not limited to healthcare

providers, government officials, public health workers, and educators may utilize this paper to

raise awareness and even implement community-wide initiatives to decrease CHD. We intend to

update this paper regularly so that all readers may be updated.

Though our paper is a meaningful step in the right direction, we aim to emphasize that advocacy

for CHD awareness goes beyond temporary efforts. It will take persistent measures for the most

powerful impact, and sustained endeavors should be spotlighted. Through such universal

collaboration, we hope to improve people's quality of life and help mitigate CHD worldwide.

“Mahalin mo ang Pusong nagmamahal”

Philippines Department of Health

52
 Acknowledgements

We thank Dr. Linda Barman, Dr. Gloria Kim, and Chloe Sales for their meaningful contributions,
expertise, and feedback on this paper.

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